|
OLUMIANT 2 MG TABLET
|
Facility
|
OP
|
$164.25
|
|
|
Service Code
|
NDC 2418230
|
| Hospital Charge Code |
25004137
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.27 |
| Max. Negotiated Rate |
$157.68 |
| Rate for Payer: Aetna Commercial |
$126.47
|
| Rate for Payer: Anthem Medicaid |
$56.49
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.12
|
| Rate for Payer: Cash Price |
$82.12
|
| Rate for Payer: Cigna Commercial |
$136.33
|
| Rate for Payer: First Health Commercial |
$156.04
|
| Rate for Payer: Humana Commercial |
$139.61
|
| Rate for Payer: Humana KY Medicaid |
$56.49
|
| Rate for Payer: Kentucky WC Medicaid |
$57.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.27
|
| Rate for Payer: Molina Healthcare Medicaid |
$57.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.54
|
| Rate for Payer: Ohio Health Group HMO |
$123.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.33
|
| Rate for Payer: PHCS Commercial |
$157.68
|
| Rate for Payer: United Healthcare All Payer |
$144.54
|
|
|
OLUMIANT 2 MG TABLET
|
Facility
|
IP
|
$164.25
|
|
|
Service Code
|
NDC 2418230
|
| Hospital Charge Code |
25004137
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$49.27 |
| Max. Negotiated Rate |
$157.68 |
| Rate for Payer: Aetna Commercial |
$126.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$128.12
|
| Rate for Payer: Cash Price |
$82.12
|
| Rate for Payer: Cigna Commercial |
$136.33
|
| Rate for Payer: First Health Commercial |
$156.04
|
| Rate for Payer: Humana Commercial |
$139.61
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$134.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$121.22
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$49.27
|
| Rate for Payer: Ohio Health Choice Commercial |
$144.54
|
| Rate for Payer: Ohio Health Group HMO |
$123.19
|
| Rate for Payer: Ohio Health Group PPO Differential |
$131.40
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$142.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$113.33
|
| Rate for Payer: PHCS Commercial |
$157.68
|
| Rate for Payer: United Healthcare All Payer |
$144.54
|
|
|
OMADACYCLINE 1MG(100MG SDV)
|
Facility
|
IP
|
$23,818.41
|
|
|
Service Code
|
HCPCS J0121
|
| Hospital Charge Code |
25004227
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7,145.52 |
| Max. Negotiated Rate |
$22,865.67 |
| Rate for Payer: Aetna Commercial |
$18,340.18
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,578.36
|
| Rate for Payer: Cash Price |
$11,909.20
|
| Rate for Payer: Cigna Commercial |
$19,769.28
|
| Rate for Payer: First Health Commercial |
$22,627.49
|
| Rate for Payer: Humana Commercial |
$20,245.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,531.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,577.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,145.52
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,960.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,863.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,054.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,722.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,434.70
|
| Rate for Payer: PHCS Commercial |
$22,865.67
|
| Rate for Payer: United Healthcare All Payer |
$20,960.20
|
|
|
OMADACYCLINE 1MG(100MG SDV)
|
Facility
|
OP
|
$23,818.41
|
|
|
Service Code
|
HCPCS J0121
|
| Hospital Charge Code |
25004227
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.01 |
| Max. Negotiated Rate |
$22,865.67 |
| Rate for Payer: Aetna Commercial |
$18,340.18
|
| Rate for Payer: Anthem Medicaid |
$8,191.15
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,578.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.61
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.41
|
| Rate for Payer: Cash Price |
$11,909.20
|
| Rate for Payer: Cash Price |
$11,909.20
|
| Rate for Payer: Cigna Commercial |
$19,769.28
|
| Rate for Payer: First Health Commercial |
$22,627.49
|
| Rate for Payer: Humana Commercial |
$20,245.65
|
| Rate for Payer: Humana KY Medicaid |
$8,191.15
|
| Rate for Payer: Humana Medicare Advantage |
$4.01
|
| Rate for Payer: Kentucky WC Medicaid |
$8,274.52
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,531.10
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,577.99
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.81
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,355.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$20,960.20
|
| Rate for Payer: Ohio Health Group HMO |
$17,863.81
|
| Rate for Payer: Ohio Health Group PPO Differential |
$19,054.73
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$20,722.02
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$16,434.70
|
| Rate for Payer: PHCS Commercial |
$22,865.67
|
| Rate for Payer: United Healthcare All Payer |
$20,960.20
|
|
|
OMEGA 3 FATTY ACIDS CAPSULE
|
Facility
|
IP
|
$4.44
|
|
|
Service Code
|
NDC 77333030810
|
| Hospital Charge Code |
25001124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
OMEGA 3 FATTY ACIDS CAPSULE
|
Facility
|
OP
|
$4.44
|
|
|
Service Code
|
NDC 77333030810
|
| Hospital Charge Code |
25001124
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.33 |
| Max. Negotiated Rate |
$4.26 |
| Rate for Payer: Aetna Commercial |
$3.42
|
| Rate for Payer: Anthem Medicaid |
$1.53
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.46
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: Cigna Commercial |
$3.69
|
| Rate for Payer: First Health Commercial |
$4.22
|
| Rate for Payer: Humana Commercial |
$3.77
|
| Rate for Payer: Humana KY Medicaid |
$1.53
|
| Rate for Payer: Kentucky WC Medicaid |
$1.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.64
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.28
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.56
|
| Rate for Payer: Ohio Health Choice Commercial |
$3.91
|
| Rate for Payer: Ohio Health Group HMO |
$3.33
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3.06
|
| Rate for Payer: PHCS Commercial |
$4.26
|
| Rate for Payer: United Healthcare All Payer |
$3.91
|
|
|
OMEGA KEYLESS HIP PLATE 130 2H
|
Facility
|
OP
|
$4,721.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,416.30 |
| Max. Negotiated Rate |
$4,532.16 |
| Rate for Payer: Aetna Commercial |
$3,635.17
|
| Rate for Payer: Anthem Medicaid |
$1,623.55
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,682.38
|
| Rate for Payer: Cash Price |
$2,360.50
|
| Rate for Payer: Cigna Commercial |
$3,918.43
|
| Rate for Payer: First Health Commercial |
$4,484.95
|
| Rate for Payer: Humana Commercial |
$4,012.85
|
| Rate for Payer: Humana KY Medicaid |
$1,623.55
|
| Rate for Payer: Kentucky WC Medicaid |
$1,640.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,871.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,484.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.30
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,656.13
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,154.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,776.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,107.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,257.49
|
| Rate for Payer: PHCS Commercial |
$4,532.16
|
| Rate for Payer: United Healthcare All Payer |
$4,154.48
|
|
|
OMEGA KEYLESS HIP PLATE 130 2H
|
Facility
|
IP
|
$4,721.00
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,416.30 |
| Max. Negotiated Rate |
$4,532.16 |
| Rate for Payer: Aetna Commercial |
$3,635.17
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,682.38
|
| Rate for Payer: Cash Price |
$2,360.50
|
| Rate for Payer: Cigna Commercial |
$3,918.43
|
| Rate for Payer: First Health Commercial |
$4,484.95
|
| Rate for Payer: Humana Commercial |
$4,012.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,871.22
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,484.10
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,416.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$4,154.48
|
| Rate for Payer: Ohio Health Group HMO |
$3,540.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,776.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4,107.27
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,257.49
|
| Rate for Payer: PHCS Commercial |
$4,532.16
|
| Rate for Payer: United Healthcare All Payer |
$4,154.48
|
|
|
OMEGA STD LAG SCREW 85MM
|
Facility
|
OP
|
$3,385.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,015.63 |
| Max. Negotiated Rate |
$3,250.02 |
| Rate for Payer: Aetna Commercial |
$2,606.79
|
| Rate for Payer: Anthem Medicaid |
$1,164.25
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,640.64
|
| Rate for Payer: Cash Price |
$1,692.72
|
| Rate for Payer: Cigna Commercial |
$2,809.92
|
| Rate for Payer: First Health Commercial |
$3,216.17
|
| Rate for Payer: Humana Commercial |
$2,877.62
|
| Rate for Payer: Humana KY Medicaid |
$1,164.25
|
| Rate for Payer: Kentucky WC Medicaid |
$1,176.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,776.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,498.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,015.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,187.61
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,979.19
|
| Rate for Payer: Ohio Health Group HMO |
$2,539.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,708.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,945.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,335.95
|
| Rate for Payer: PHCS Commercial |
$3,250.02
|
| Rate for Payer: United Healthcare All Payer |
$2,979.19
|
|
|
OMEGA STD LAG SCREW 85MM
|
Facility
|
IP
|
$3,385.44
|
|
|
Service Code
|
HCPCS C1713
|
| Hospital Charge Code |
27000005
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,015.63 |
| Max. Negotiated Rate |
$3,250.02 |
| Rate for Payer: Aetna Commercial |
$2,606.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,640.64
|
| Rate for Payer: Cash Price |
$1,692.72
|
| Rate for Payer: Cigna Commercial |
$2,809.92
|
| Rate for Payer: First Health Commercial |
$3,216.17
|
| Rate for Payer: Humana Commercial |
$2,877.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,776.06
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,498.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,015.63
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,979.19
|
| Rate for Payer: Ohio Health Group HMO |
$2,539.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,708.35
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,945.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,335.95
|
| Rate for Payer: PHCS Commercial |
$3,250.02
|
| Rate for Payer: United Healthcare All Payer |
$2,979.19
|
|
|
OMENTAL FLAP INTRA-ABDOM
|
Facility
|
IP
|
$1,775.00
|
|
|
Service Code
|
HCPCS 49905
|
| Hospital Charge Code |
76102042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
|
OMENTAL FLAP INTRA-ABDOM
|
Professional
|
Both
|
$1,775.00
|
|
|
Service Code
|
HCPCS 49905
|
| Hospital Charge Code |
76102042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$303.37 |
| Max. Negotiated Rate |
$1,065.00 |
| Rate for Payer: Aetna Commercial |
$534.77
|
| Rate for Payer: Ambetter Exchange |
$333.74
|
| Rate for Payer: Anthem Medicaid |
$303.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$333.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$333.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$400.49
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$508.78
|
| Rate for Payer: Healthspan PPO |
$450.98
|
| Rate for Payer: Humana Medicaid |
$303.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$457.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$333.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$333.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$309.44
|
| Rate for Payer: Molina Healthcare Passport |
$303.37
|
| Rate for Payer: Multiplan PHCS |
$1,065.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$433.86
|
| Rate for Payer: UHCCP Medicaid |
$621.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$306.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$333.74
|
|
|
OMENTAL FLAP INTRA-ABDOM
|
Facility
|
OP
|
$1,775.00
|
|
|
Service Code
|
HCPCS 49905
|
| Hospital Charge Code |
76102042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$532.50 |
| Max. Negotiated Rate |
$1,704.00 |
| Rate for Payer: Aetna Commercial |
$1,366.75
|
| Rate for Payer: Anthem Medicaid |
$610.42
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,384.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$1,473.25
|
| Rate for Payer: First Health Commercial |
$1,686.25
|
| Rate for Payer: Humana Commercial |
$1,508.75
|
| Rate for Payer: Humana KY Medicaid |
$610.42
|
| Rate for Payer: Kentucky WC Medicaid |
$616.63
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$1,455.50
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,309.95
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$532.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$622.67
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,562.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,331.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,420.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,544.25
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,224.75
|
| Rate for Payer: PHCS Commercial |
$1,704.00
|
| Rate for Payer: United Healthcare All Payer |
$1,562.00
|
|
|
OMENTAL FLAP INTRA-ABDOM(P
|
Professional
|
Both
|
$1,775.00
|
|
|
Service Code
|
HCPCS 49905
|
| Hospital Charge Code |
761P2042
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$303.37 |
| Max. Negotiated Rate |
$1,065.00 |
| Rate for Payer: Aetna Commercial |
$534.77
|
| Rate for Payer: Ambetter Exchange |
$333.74
|
| Rate for Payer: Anthem Medicaid |
$303.37
|
| Rate for Payer: Buckeye Individual/Medicaid |
$333.74
|
| Rate for Payer: Buckeye Medicare Advantage |
$333.74
|
| Rate for Payer: CareSource Just4Me Medicare |
$400.49
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cash Price |
$887.50
|
| Rate for Payer: Cigna Commercial |
$508.78
|
| Rate for Payer: Healthspan PPO |
$450.98
|
| Rate for Payer: Humana Medicaid |
$303.37
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$457.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$333.74
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$333.74
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$309.44
|
| Rate for Payer: Molina Healthcare Passport |
$303.37
|
| Rate for Payer: Multiplan PHCS |
$1,065.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$433.86
|
| Rate for Payer: UHCCP Medicaid |
$621.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$306.40
|
| Rate for Payer: Wellcare Medicare Advantage |
$333.74
|
|
|
OMENTECOMTY W/BSO
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 58950
|
| Hospital Charge Code |
76102264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$773.05 |
| Max. Negotiated Rate |
$1,615.85 |
| Rate for Payer: Aetna Commercial |
$1,615.85
|
| Rate for Payer: Ambetter Exchange |
$1,089.79
|
| Rate for Payer: Anthem Medicaid |
$773.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,089.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,089.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,307.75
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,573.36
|
| Rate for Payer: Healthspan PPO |
$1,564.55
|
| Rate for Payer: Humana Medicaid |
$773.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,399.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,089.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,089.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$788.51
|
| Rate for Payer: Molina Healthcare Passport |
$773.05
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,416.73
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$780.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,089.79
|
|
|
OMENTECOMTY W/BSO
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 58950
|
| Hospital Charge Code |
76102264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem Medicaid |
$859.75
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Humana KY Medicaid |
$859.75
|
| Rate for Payer: Kentucky WC Medicaid |
$868.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$877.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
OMENTECOMTY W/BSO
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 58950
|
| Hospital Charge Code |
76102264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$750.00 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna Commercial |
$1,925.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$1,950.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$2,075.00
|
| Rate for Payer: First Health Commercial |
$2,375.00
|
| Rate for Payer: Humana Commercial |
$2,125.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,050.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,845.00
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$750.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,200.00
|
| Rate for Payer: Ohio Health Group HMO |
$1,875.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,000.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,175.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,725.00
|
| Rate for Payer: PHCS Commercial |
$2,400.00
|
| Rate for Payer: United Healthcare All Payer |
$2,200.00
|
|
|
OMENTECOMTY W/BSO(P
|
Professional
|
Both
|
$2,500.00
|
|
|
Service Code
|
HCPCS 58950
|
| Hospital Charge Code |
761P2264
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$773.05 |
| Max. Negotiated Rate |
$1,615.85 |
| Rate for Payer: Aetna Commercial |
$1,615.85
|
| Rate for Payer: Ambetter Exchange |
$1,089.79
|
| Rate for Payer: Anthem Medicaid |
$773.05
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,089.79
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,089.79
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,307.75
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cash Price |
$1,250.00
|
| Rate for Payer: Cigna Commercial |
$1,573.36
|
| Rate for Payer: Healthspan PPO |
$1,564.55
|
| Rate for Payer: Humana Medicaid |
$773.05
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,399.98
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,089.79
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,089.79
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$788.51
|
| Rate for Payer: Molina Healthcare Passport |
$773.05
|
| Rate for Payer: Multiplan PHCS |
$1,500.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,416.73
|
| Rate for Payer: UHCCP Medicaid |
$875.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$780.78
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,089.79
|
|
|
OMENTECOMTY W/TAH & LN BX
|
Facility
|
IP
|
$4,200.00
|
|
|
Service Code
|
HCPCS 58951
|
| Hospital Charge Code |
76102265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$4,032.00 |
| Rate for Payer: Aetna Commercial |
$3,234.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,276.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$3,486.00
|
| Rate for Payer: First Health Commercial |
$3,990.00
|
| Rate for Payer: Humana Commercial |
$3,570.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,444.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,099.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,260.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,696.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,654.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,898.00
|
| Rate for Payer: PHCS Commercial |
$4,032.00
|
| Rate for Payer: United Healthcare All Payer |
$3,696.00
|
|
|
OMENTECOMTY W/TAH & LN BX
|
Professional
|
Both
|
$4,200.00
|
|
|
Service Code
|
HCPCS 58951
|
| Hospital Charge Code |
76102265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,184.26 |
| Max. Negotiated Rate |
$2,520.00 |
| Rate for Payer: Aetna Commercial |
$2,086.28
|
| Rate for Payer: Ambetter Exchange |
$1,368.12
|
| Rate for Payer: Anthem Medicaid |
$1,184.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,368.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,368.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,641.74
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$2,034.56
|
| Rate for Payer: Healthspan PPO |
$2,020.05
|
| Rate for Payer: Humana Medicaid |
$1,184.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,800.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,368.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,368.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,207.95
|
| Rate for Payer: Molina Healthcare Passport |
$1,184.26
|
| Rate for Payer: Multiplan PHCS |
$2,520.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,778.56
|
| Rate for Payer: UHCCP Medicaid |
$1,470.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,196.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,368.12
|
|
|
OMENTECOMTY W/TAH & LN BX
|
Facility
|
OP
|
$4,200.00
|
|
|
Service Code
|
HCPCS 58951
|
| Hospital Charge Code |
76102265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,260.00 |
| Max. Negotiated Rate |
$4,032.00 |
| Rate for Payer: Aetna Commercial |
$3,234.00
|
| Rate for Payer: Anthem Medicaid |
$1,444.38
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,276.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$3,486.00
|
| Rate for Payer: First Health Commercial |
$3,990.00
|
| Rate for Payer: Humana Commercial |
$3,570.00
|
| Rate for Payer: Humana KY Medicaid |
$1,444.38
|
| Rate for Payer: Kentucky WC Medicaid |
$1,459.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,444.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,099.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,260.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,473.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,696.00
|
| Rate for Payer: Ohio Health Group HMO |
$3,150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,360.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,654.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,898.00
|
| Rate for Payer: PHCS Commercial |
$4,032.00
|
| Rate for Payer: United Healthcare All Payer |
$3,696.00
|
|
|
OMENTECOMTY W/TAH & LN BX(P
|
Professional
|
Both
|
$4,200.00
|
|
|
Service Code
|
HCPCS 58951
|
| Hospital Charge Code |
761P2265
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$1,184.26 |
| Max. Negotiated Rate |
$2,520.00 |
| Rate for Payer: Aetna Commercial |
$2,086.28
|
| Rate for Payer: Ambetter Exchange |
$1,368.12
|
| Rate for Payer: Anthem Medicaid |
$1,184.26
|
| Rate for Payer: Buckeye Individual/Medicaid |
$1,368.12
|
| Rate for Payer: Buckeye Medicare Advantage |
$1,368.12
|
| Rate for Payer: CareSource Just4Me Medicare |
$1,641.74
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: Cigna Commercial |
$2,034.56
|
| Rate for Payer: Healthspan PPO |
$2,020.05
|
| Rate for Payer: Humana Medicaid |
$1,184.26
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,800.01
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$1,368.12
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,368.12
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$1,207.95
|
| Rate for Payer: Molina Healthcare Passport |
$1,184.26
|
| Rate for Payer: Multiplan PHCS |
$2,520.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$1,778.56
|
| Rate for Payer: UHCCP Medicaid |
$1,470.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$1,196.10
|
| Rate for Payer: Wellcare Medicare Advantage |
$1,368.12
|
|
|
OMENTECTOMY
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 49255
|
| Hospital Charge Code |
76101986
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
OMENTECTOMY
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
HCPCS 49255
|
| Hospital Charge Code |
76101986
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$360.00 |
| Max. Negotiated Rate |
$1,152.00 |
| Rate for Payer: Aetna Commercial |
$924.00
|
| Rate for Payer: Anthem Medicaid |
$412.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$936.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$996.00
|
| Rate for Payer: First Health Commercial |
$1,140.00
|
| Rate for Payer: Humana Commercial |
$1,020.00
|
| Rate for Payer: Humana KY Medicaid |
$412.68
|
| Rate for Payer: Kentucky WC Medicaid |
$416.88
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$984.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$885.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$360.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$420.96
|
| Rate for Payer: Ohio Health Choice Commercial |
$1,056.00
|
| Rate for Payer: Ohio Health Group HMO |
$900.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$960.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,044.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$828.00
|
| Rate for Payer: PHCS Commercial |
$1,152.00
|
| Rate for Payer: United Healthcare All Payer |
$1,056.00
|
|
|
OMENTECTOMY
|
Professional
|
Both
|
$1,200.00
|
|
|
Service Code
|
HCPCS 49255
|
| Hospital Charge Code |
76101986
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$284.89 |
| Max. Negotiated Rate |
$1,126.51 |
| Rate for Payer: Aetna Commercial |
$1,126.51
|
| Rate for Payer: Ambetter Exchange |
$755.37
|
| Rate for Payer: Anthem Medicaid |
$284.89
|
| Rate for Payer: Buckeye Individual/Medicaid |
$755.37
|
| Rate for Payer: Buckeye Medicare Advantage |
$755.37
|
| Rate for Payer: CareSource Just4Me Medicare |
$906.44
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cash Price |
$600.00
|
| Rate for Payer: Cigna Commercial |
$1,049.27
|
| Rate for Payer: Healthspan PPO |
$950.01
|
| Rate for Payer: Humana Medicaid |
$284.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$1,001.94
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$755.37
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$755.37
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$290.59
|
| Rate for Payer: Molina Healthcare Passport |
$284.89
|
| Rate for Payer: Multiplan PHCS |
$720.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$981.98
|
| Rate for Payer: UHCCP Medicaid |
$420.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$287.74
|
| Rate for Payer: Wellcare Medicare Advantage |
$755.37
|
|
